Asherman’s Syndrome

Asherman’s Syndrome is the presence of scar tissue within the womb, often as a result of a miscarriage. Many women come to WHRIA for advice and relief from their symptoms, which can include reduced menstrual flow, pain with menstruation and/or difficulty getting pregnant again.

What is Asherman’s Syndrome?

Named after Dr Asherman, an Israeli gynaecologist who first described the condition in the mid twentieth century, Asherman’s Syndrome is a reduction or absence in menstruation for any reason other than lack of hormones (menopause). Reduced menstrual flow is caused by the formation of scar tissue inside the cervix and uterus. Scar tissue can form as a result of a recent pregnancy or delivery, infection, inflammation or any gynaecological surgical procedure.

What causes Asherman’s Syndrome?

The majority of cases (over 95%) are associated with infections or complications from surgical procedures involving the pregnant, or recently pregnant, uterus. The likelihood of developing Asherman’s Syndrome increases in cases where the mother has miscarried, terminated the pregnancy between 12 and 20 weeks, or if a surgical procedure has to be repeated. Some women may be born with a genetic susceptibility to develop dense scars, and age can play a part too.

Scar tissue is most likely to form on the inner surfaces of the uterus that do not regenerate each month, such as the cervical canal (entrance to the cavity) and the tubal ostia (entrance to the fallopian tubes). It is also known to form on the endometrium, as during pregnancy the endometrium’s ability to respond to injury is reduced.

Asherman’s Syndrome can develop in a non-pregnant uterus, and can result from the surgical removal of fibroids (myomectomy). Fibroids cause the entire uterus to enlarge, stretching the blood vessels and making them susceptible to blockages when the fibroids are removed, as they inevitably shrink back to size. Due to the lack of oxygen and nutrients, that area of tissue dies and a scar forms.

There are also theories that radiation treatment to the pelvis can lead to the formation of scars, as it can reduce blood flow to the uterus and ovaries may produce less oestrogen after radiation exposure.

How do I know if I have Asherman’s Syndrome?

You’ll notice a reduction in or absence of your menstrual flow. If you’re still having a period, you might experience some mild to severe pain with it, as the uterine muscle has to work harder to push the menstrual fluid past the scar tissue. Hospital admission may be required if a haematometra forms, essentially a large bruise inside the uterus, to relieve the pressure caused by the build up of menstrual fluid.

It’s also quite possible that many women with Asherman’s Syndrome don’t have any symptoms at all, or the change in flow is so minimal they don’t notice it.

Can I still conceive if I have Asherman’s Syndrome?

It’s currently uncertain whether scarring in the uterus has a significant clinical effect on fertility or menstrual function. If you have recently had a surgical procedure on your uterus, or notice that your periods are much lighter or more painful than normal, and you are having difficulty conceiving you should book an appointment with your GP to arrange a hysteroscopy.

What are the stages of Asherman’s Syndrome?

Stage I

Minor scarring in either the cervical canal or the uterine cavity.

Unless this involves a specific area of the uterus called the isthmus, there will be little impact on normal function of the uterus and treatment is not essential.

However if the scar involves the isthmus there can be a significant impact on the function of the endometrium and you should seek treatment.

Most women are able to fall pregnant again.

Stage II

We most frequently see patients presenting at this stage of the condition.

There will be an obstruction of the inner os, a tiny part of the cervix that opens into the uterus and is easily blocked.

In some women this obstruction involves only a fraction of a millimetre, in others it can stretch over several centimetres.

If the scarring involves the very low end of the uterine cavity (the isthmus), there will be no production of menstrual blood and no pain.

In some cases women might experience mild cramps with no bleeding, though this is not as common.

Women with stage II Asherman’s syndrome have more than a 60% chance of conceiving again.

Stage III

The uterus will normally contract and more than 50% is blocked by scar tissue.

There may also be an obstruction of one of the tubal orifices.

The greater the extent of scar formation, the more difficult it is to treat.

Typically, women have less than a 30% chance of successfully conceiving and delivering a child.

Stage IV

More than 75% of the uterus is blocked and it is smaller in size.

Treatment at this stage requires multiple visits and has a low success rate.

With the introduction of stem cell technology, results may improve in the future.

How is Asherman’s Syndrome treated?

Our treatment protocol is the result of over 20 years’ experience. We’ve seen excellent results, with most women seeing a return to normal menstrual flow, and over 60% of women able to conceive again.

Regardless of the stage of Asherman’s Syndrome you are presenting, we will organise an appointment with one of our experienced doctors, ideally so it falls in the early phase of your menstrual cycle. This way, if surgery is required it can be performed in the following days. We’ll perform an ultrasound examination of your uterus to determine the location and extent of the scarring, as well as screen for other conditions such as ovarian cysts or cervical lesions that may cause complications during surgery.

Your surgery will be scheduled between day three and 12 of the menstrual cycle. To reduce the risk of infection we will prescribe antibiotics that you should start taking two days before your surgery and for five days afterwards.

A typical procedure to treat Asherman’s Syndrome:

You’ll be placed under general or local anaesthesia

Once you are safely sedated, a telescope called a hysteroscope is inserted into the uterus through the cervix (no cuts are made) and the presence and extent of the scarring is noted.

Sometimes it is not possible to see inside the uterus immediately and sonography or X-rays are used. We will only use X-rays where sonography is unsuccessful to limit your potential exposure to radiation.

Micro-scissors are used through the hysteroscope to start to remove scar tissue.

The surgeon slowly opens up all the pockets of normal endometrial lining to reconstruct a near normal cavity.

Usually, you’ll take oestrogen medication for the next three weeks to stimulate the repair of the endometrium and growth of new small vessels, and reduce the likelihood of scar formation.

Hyaluronic Acid gel is placed in the uterus to promote healing and help maintain a physical barrier between the front and back walls of the uterus.

If you have advanced scarring (some stage II cases and most stage III and IV cases) you may need to undergo the procedure twice. You’ll take the oestrogen supplement between the two operations, which are spaced between four and 12 weeks apart.

Once you stop taking the oestrogen supplement, your period will typically resume ten to 40 days later.

After spontaneous menstruation, we will perform another ultrasound to check that the uterus is functioning normally. We recommend repeat surgery if the ultrasound shows the presence of persistent scarring or if periods do not occur spontaneously within three months of the initial surgery.

For stages III and IV, we will always perform a second ultrasound, looking carefully for any residual endometrium.

Surgical management of the later stages of Asherman’s Syndrome is rapidly evolving, and you will receive treatment tailored to your symptoms. Currently, we prefer to use activated platelets from your own blood, which are instilled into the surgically created uterine cavity and can provide an improved outcome.

Note: WHRIA does participate in clinical research, which means we may change our treatment protocol at times.

Asherman’s Syndrome myths… busted

Myth: Asherman’s Syndrome is caused by aggressive scraping of the womb following a miscarriage.

Fact: There is no scientific basis to substantiate this myth, though there is a link between an incomplete procedure following a miscarriage and the formation of scar tissue. We recommend an ultrasound be performed to determine whether the procedure was successful.

Myth: I’ll only need one surgery to remove scar tissue.

Fact: The number of surgeries required will vary from patient to patient and depends on the location and extent of the scarring. Over half of women only need one surgery, while others require as many as six, and we recommend an ultrasound to determine the cavity’s recovery.

Myth: Once my scars are removed I can fall pregnant straightaway.

Fact: We recommend that you wait for one normal menstrual cycle after you have stopped taking hormonal supplements and have had confirmation from your doctor that the cavity is back to normal. We also recommend trying for at least six months before doing any further testing.

Myth: After treatment I’ll only be able to deliver a baby through a Cesarean Section

Fact: There is no general rule to this myth and it will depend on whether the placenta has invaded the uterine wall or not. Only in the presence of suspected abnormal placentation do we recommend a planned Cesarean Section.

Myth: Asherman’s Syndrome is a life-long condition

Fact: While we can remove the scarring within the uterus, unfortunately a scarred uterus remains a scarred uterus. Treatment can improve the anatomy to allow a pregnancy to occur, however changes which involve the deeper layers of the uterus are likely to remain to a certain extent.

Myth: Asherman’s Syndrome should always be treated

Fact: If you do not have painful symptoms and are certain that you don’t want to have any more children, then there is no need to treat Asherman’s syndrome. No harm will come from the presence of the scar tissue itself, though you may have reduced or no periods until you reach menopause.